Healthcare Provider Details

I. General information

NPI: 1346903812
Provider Name (Legal Business Name): THADDEUS HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 N 8TH ST STE 127
KILLEEN TX
76541-5215
US

IV. Provider business mailing address

1055 NIAGARA HTS
BELTON TX
76513-8175
US

V. Phone/Fax

Practice location:
  • Phone: 713-832-2027
  • Fax:
Mailing address:
  • Phone: 254-519-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: